Ruminations by a non-academic general surgeon from the heart of the rust belt.

Monday, August 4, 2008

Captain of the ship

I've written ad nauseum about the burgeoning problem of having too many cooks in the kitchen with regards to critically ill surgical patients. Standard operating procedure for a patient who arrives in the ER toxic from peritonitis: Consult GI, the hospitalist, ID, nephrology, a pulmonologist/intensivist, and, what the heck, a general surgeon. Patient has a surgical problem. Patient undergoes emergency surgery. Nurses spend the next two weeks pulling out their hair trying to keep straight all the conflicting orders written on the chart from the various consultants. That's life in American ICU's.

I recently wrote about a vasculopathic lady who presented with an infarcted sigmoid colon. Post operatively she sort of limped along. By post-op day #5, she still hadn't turned the corner and, in fact, seemed to be deteriorating. I just didn't like the way she looked. And her abdomen was more tender. And her WBC count kept rising. So I took her back for another exploration; sure enough, patchy areas of ischemia were apparent throughout the remaining colon, especially in the area of the cecum. I performed a completion colectomy and gave her an end ileostomy. There were palpable pulses in the mesentery, but the vessels were hard, calcified pipes. Clearly, this was a case of Non-occlusive mesenteric ischemia (NOMI), with the disease affecting the blood supply at the level of the arterioles. Classic teaching is that this form of mesenteric ischemia carries the worst prognosis because there are no real interventions to reverse the problem. All you can do is resect the dying bowel and hope the disease is limited to the colon.

I wrote in the chart an honest appraisal of her poor overall prognosis. The first 48hours were rough, but she was hanging in there. The stoma looked pink and viable. She was maintaining her blood pressure. Not a perfect picture, but at least some semblance of hope remained. The hospitalist called me early that Monday. He had read the notes I left in the chart. He was picking up the patient from his colleague and he wanted to know my feelings on the overall outlook. I reiterated that, although the prognosis wasn't good, she actually wasn't doing bad, either. Apparently, a conversation ensued later on that evening between the hospitalist and the family and there was a decision to implement comfort care measures and a gradual withdrawal of all supportive care. This was a decision that was made without my knowledge.

I came in the next morning and I was a bit mystified to find my patient lying alone in a darkened ICU room with all the monitors shut off, no IV's running, completely disconnected from any form of supportive care. What's going on? I inquired. They made the patient DNR-CC last night, the nurse replied. I see. So they did.

I flip through the chart and read the hospitalist's note. After a discussion of the likely outcomes, the family decided to start withdrawal of care. The orders read as follows: DNR-CC, d/c labs, d/c dialysis, d/c TPN, d/c antibiotics, transfer to regular floor when bed available. At this point my temporal artery is pounding in my forehead and I've broken out in a cold sweat. But very calmly I sit down,take a few deep breaths, and I start to make some phone calls. I arrange for the family to meet me at bedside. I tell the charge nurse to give me a few hours before sending her upstairs. My patient is sleeping comfortably in bed. I check her blood pressure; 112/65. She's saturating 99% on 4liters of oxygen. She opens her eyes and smiles when I say her name. The stoma has started to put out green enteric contents.

Basically I have to ask the family to reconsider probably the hardest decision they ever had to make. She's maintaining her pressure. She's breathing on her own. Her GI tract is starting to work. We may have something to work with here, I told them. I've been with her from the beginning. You know me; I wouldn't try to mislead you. I think she may have a chance. The poor husband just stared straight head, eyes glistening, shaking his head. He'd spent an hour talking to a priest the previous night, second guessing his decision to make his wife DNR-CC.

In medicine there has to be a captain of the ship. One voice. One person to speak to the family. My mistake was taking it for granted that that role would fall on me, as the operating surgeon. The hospitalist, not to be too hard on him, was simply doing his job. He read the chart, spoke to me on the phone, and made a decision based on his interpretation of the situation. Perhaps he went a little too far, but in these ICU patients where there are no clearly defined boundaries for each specialist, how do you know when you've gone too far?

The family agreed to re-institute full care. I spent the next hour frantically re-ordering everything that had been stopped. My patient had been without any form of support for 16 hours; valuable time had been lost. They dialyzed her later that night. Antibiotics were restarted. Aggressive pulmonary toilet was implemented. After a couple of days, she started to turn the corner. She's on the regular floor now. She's eating and slowly getting back her strength. I think she might make it. And I almost lost her because I wasn't adamant enough in seizing control of the ship. There is a time for collegial collaboration and a time for dictatorship when a patient's life is at stake. The challenge is to find that delicate balance in one's practice......

14 comments:

this story actually makes me more than slightly annoyed. why the hell did the hospitalist think you took her back if you were just going to pull the plug? i can't imagins such arrogance as to take your patient right out from under your nose.

thankfully we are not cursed with hospitalists in my country. of course you must be the captain of the ship if it was you that operated the patient.

i think your system is crazy. if i operate someone i sure as hell am not going to allow some upstarrt to make decisions on that patient, especially decisions to withdraw treatment.

The captain of the ship is he/she who answers their pager the fastest. That's my experience. Buckeye, I would never institute comfort cares without getting all docs opinions, unless of course the family wants it in spite of the medical opinions.

bongi, I am not a curse, but I do know a little voodoo. The attending on record is the captain, inspite of who did what to whom. A post surgical patient is no more owned by a surgeon than they are by the kidney doctor doing dialysis, as they are by the heart doctor managing their afib, as they are by the hospitalist coordinating everything else.

The captain is a collaberation of expert opinions, of which all the physicians bring to the table. Its the coordination and disposition that really drives expectations and discharge planning. But for any one physician to over ride another without respectful communication and working out their differences is bad for the team. When that happens, I excuse myself from the case for the good of the team.

Buckeye - Wow, that's horrible; but so great that she's doing well. I've seen close to that, and in fact had to push some over eager pulmonologists off of my patients, and stop the neurologists from declaring people brain-dead when they're not; but for sheer unbelievable mismanagement, your story takes the cake. . .

People blame surgeons (and oncologists) for being too hopeful, wanting to continue too long when there's no hope; but sometimes, even our over-intensive system can err towards giving up too soon.

"doing well" - define! As a medical professional and as the daughter of a terminal patient that a well meaning pulmonolgist aggressively wanted to vent telling me, "he'll have a good quality of life" (you and I both know he would NEVER get off that vent and in fact would end up, as a COPD pt post MI and post pneumonia, with a horrific quality of life). So, respectfully I ask just what you mean by 'doing well', because being alive most certainly does not equal doing well.

Alice, the problem with we operate, we are responsible ends rather quickly once the surgeon leaves academia. In the private practice world, in my experience, we are consulted on just about every patient with any medical issues, from end stage liver disease and heart failure, to a hang nail. The problem with we operate, we own, is that in the private practice world, we (hospitalists/intensivists, cardiologists, nephrologists/infectioists) get all the phone calls. The day to day post operative complications and medical issues simply aren't owned by the surgeon like they are in academia. That is my experience in the private practice world. It was an entirely different beast in academia, when I as an internist rarely came in contact with a surgical patient.

And I rarely, if ever see a surgeon manage the heart failure, afib, renal failure, ventilator, diabetes, hypertension. It simply doesn't happen in the private practice world.

I am a Family Physician and I see this in my community hospital as well. I see it more since we have obtained hospitalists. I appreciate and understand the ability of a hospitalist to deliver great care and do it better and cheaper than me. I have seen hospitalist programs be implemented at two of the hospitals I work in and initially, the intent for communication is wonderful. We all talk about calling the PCP and involving them in the decisions - to help with the family, to get extended histories, etc. Somewhere, this communication breaks down - and often never occurs. I know it is often difficult to identify a patients PCP and then get them on the phone when convenient for both physicians.

Obviously, communication is key - we are always in a rush (for more reasons than can be listed) and in the end this is clearly detrimental to our patients.

I appreciate the story - and might add here - am always happy to be the captain, interface with the family and all specialists on the case - especially in the ICU setting where I might be writing very few orders. Coordination is where my time is best spent.

Buckeye:The hospitalist clearly should have had you in the loop as you were the one who operated, but who was the primary doc here?

Alice:To echo HH, in my opinion it is now the rare surgeon in private practice who takes primary responsibility for hospitalized patients. Usually, those surgeons who do are general surgeons. In my expereince, very few neurosurgeons, orthopods, urologists, ENT's, actively manage their patients after the surgery anymore. one week days from 11:00-18:00 the medical management c/s come rolling in. The sad fact is many don't really need our input, not to mention the added bill of another doc. That is now the reality of private practice.

I have to second anonymous... it is very rare to have a surgeon take that much interest in a post-op patient in my hospital! Even those who are still under the surgery attending in the SICU are pretty much thrown to the housestaff for management.

I'm glad that there are some surgeons who take such an interest and are willing to sit down with families to discuss plans and prognosis. I hope you're teaching your residents to do the same.

Thanks for the interesting post. An important part of the conversation with patients and families is understanding what lead to the decision to change from aggressive, curative measures to comfort as the primary goal. It may be dependent on more then just one clinician's estimation of prognosis.

Based on the hospitalist's discussion with you it is not entirely unreasonable that a family meeting could have resulted in the change to comfort measures. I noted that the hospitalist did not call you after the meeting, but there also was no mention of you calling the hospitalist before reconvening the family to get the 'unwritten details' of the family meeting. His note may have been sufficient to explain the reasoning. Unfortunately the documentation of family meetings when these decisions are made don't always explain the foundations for the change in the decision.

As a palliative care doctor, I will often ask some of the key docs (primary, and major consultants) before our family meeting if they would be agreeable if the family decide to forego further aggressive management. I also try to make explicit in a concise way why the change was made.

And one thing that is very important for many health care professionals to realize is that for palliative care teams*, the goal of a family meeting is never to come out with a DNR, but rather to:

1)find out what the patient/family knows about the condition2)answer questions that have gone unanswered or been misunderstood3)elicit their preferences for care based on current knowledge of the diagnosis and prognosis

*I know a palliative care team was not referenced in the posted case, but I am talking from my experience in dealing with medical decision making form a palliative care team perspective.

Seems a little premature for the hospitalist (that is the new name for internal med docs, no?)to consider DNR-CC as the only option for the pt and family. Sounds more like an administrative move. What torture for the husband! At least they let her have O2 and she held her own until you rescued her.

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